“I reluctantly conclude we have a system-wide problem”
— Commission co-chairman William K. Reilly
UPDATED TO INCLUDE LINKS TO FINAL REPORT
WSJ – By STEPHEN POWER And BEN CASSELMAN
The explosion that triggered last year’s Gulf of Mexico oil spill was an avoidable disaster that resulted from management failures by BP PLC and its contractors, a presidential commission has concluded. But the accident also reflected systemic failures by oil companies and regulators to deal with the risks of deep-water exploration, the panel said.
A report by the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling castigates BP and two of the British oil giant’s contractors—Transocean Ltd. and Halliburton Co.—for missteps that contributed to the worst offshore oil spill in U.S. history and the deaths of 11 rig workers.
The problems go far beyond BP, however, the report concludes—disputing oil-industry arguments that the April 20 explosion on the Deepwater Horizon rig was a one-time event caused by unusual and risky decisions by the oil company.
The panel said all three companies did a poor job of assessing the risks associated with their decisions and failed to adequately communicate, either with one another or with their own employees. Federal regulators lacked training and manpower to properly police the industry, the report finds.
The blowout “was not the product of a series of aberrational decisions made by rogue industry or government officials that could not have been anticipated or expected to occur again,” according to a chapter of the report released Wednesday. “Rather, the root causes are systemic and, absent significant reform in both industry practices and government policies, might well recur.”
…That conclusion could give regulators more ammunition to pursue tougher safety rules. At the same time, such efforts may be muted by pressure from lawmakers in both parties to allow deep-water drilling to resume.
BP said the excerpt released Wednesday, like the company’s own internal investigation, concluded the accident “was the result of multiple causes, involving multiple companies.”
BP added that it was working to ensure that lessons learned led to improvements in deep-water drilling, and that it had already made changes to strengthen safety and risk management.
A Transocean spokesman said procedures at the well in the final hours were directed by BP and approved by regulators. “Based on the limited information made available to them, the Transocean crew took appropriate actions to gain control of the well,” he said.
Halliburton, which handled a cement seal on the well, said cement jobs “can go wrong even under optimal conditions.” The company added that its cement mixture was designed to BP’s specifications and passed its final laboratory test.
President Barack Obama, in setting up the seven-member panel last summer, said he wanted it to recommend safety and environmental precautions the government should take to prevent mishaps. Several other government entities, including the Justice Department, are conducting their own investigations…
In September, BP issued its own internal investigation into the disaster, which concluded that although its workers bore partial responsibility for misinterpreting a key pressure test, most of the blame for the disaster lay with its contractors. In particular, BP blamed a bad cementing job by Halliburton and the failure of Transocean workers to detect and react to signs that explosive natural gas was entering the well.
The commission’s report criticizes all three companies, but focuses most heavily on BP, which owned the well and oversaw drilling operations.
The report identifies nine decisions that increased risk while potentially saving time, and said BP was responsible for at least seven of them. The report doesn’t accuse BP of actively choosing cost savings over safety, but says the company failed to put in place procedures to ensure that efforts to curb costs didn’t compromise safety…
Gulf Oil Spill: Methane Gas Concentrations in Gulf of Mexico Quickly Returned to Near-Normal Levels, Surprising Researchers
Calling the results “extremely surprising,” researchers from the University of California, Santa Barbara and Texas A&M University report that methane gas concentrations in the Gulf of Mexico have returned to near normal levels only months after a massive release occurred following the Deepwater Horizon oil rig explosion.
Findings from the research study, led by oceanographers John Kessler of Texas A&M and David Valentine of UCSB, were recently published in the journal Science. The findings show that Mother Nature quickly saw to the removal of more than 200,000 metric tons of dissolved methane through the action of bacteria blooms that completely consumed the immense gas plumes the team had identified in mid-June.
At that time, the team reported finding methane gas in amounts 100,000 times above normal levels. But, about 120 days after the initial spill, they could find only normal concentrations of methane and clear evidence of complete methane respiration.
“What we observed in June was a horizon of deep water laden with methane and other hydrocarbon gases,” Valentine said. “When we returned in September and October and tracked these waters, we found the gases were gone. In their place were residual methane-eating bacteria, and a 1 million ton deficit in dissolved oxygen that we attribute to respiration of methane by these bacteria.”
Kessler added: “Based on our measurements from earlier in the summer and previous other measurements of methane respiration rates around the world, it appeared that (Deepwater Horizon) methane would be present in the Gulf for years to come. Instead, the methane respiration rates increased to levels higher than have ever been recorded, ultimately consuming it and prohibiting its release to the atmosphere.”…]
By Mark Schleifstein, The Times-Picayune
Louisiana’s coastline continues to be smeared with significant amounts of oil and oiled material from the BP Deepwater Horizon disaster, with cleanup teams struggling to remove as much as possible of the toxic material by the time migratory birds arrive at the end of February, said the program manager of the Shoreline Cleanup and Assessment Teams, which are working for BP and the federal government.
There are 113 miles of Louisiana coastline under active cleanup, with another 55 miles awaiting approval to start the cleanup process, according to SCAT statistics. Teams have finished cleaning almost 72 miles to levels where oil is no longer observable or where no further treatment is necessary.
But that’s not the whole story for the state’s coastline. According to SCAT statistics, there’s another 2,846 miles of beach and wetland areas where oil was once found but is no longer observable or is not treatable.
Gary Hayward, the Newfields Environmental Planning and Compliance contractor who oversees the SCAT program, said that large area will be placed into a new “monitor and maintenance” category, once Louisiana state and local officials agree to the procedures to be used for that category.
“With rare exceptions, most of the marshes still have a bathtub ring that we have all collectively decided we aren’t going to clean any more than we already have because we’d be doing more harm to the marshes than the oil is going to be doing to them,” Hayward said.
The cleanup protocols for each state have been approved by state and local governments, federal agencies and BP, he said.
Louisiana’s senior coastal official says the state is monitoring the cleanup, and remains concerned with end-of-year conclusions that the cleanup is almost complete.
“The reality is we still have hundreds of miles of oiled shoreline today,” said Garret Graves, chairman of the Coastal Protection and Restoration Authority. “We still have oilings on a regular basis in areas of Jefferson and Plaquemines Parish, and there’s still a lot of oil buried back in the marshes where it was carried during high water events.
“The threat is absolutely still there and the oil is absolutely still there,” he said…
Mats of weathered oil
However, the cleanup plan is still struggling with tar balls and other material washing ashore from mats of weathered oil that are located in the surf zone just off several key beach areas, including Pensacola, Fla.; Bon Secour National Wildlife Refuge at Gulf Shores, Ala.; and the barrier islands off Mississippi’s coast. Officials are concerned submerged tar mats may also be the source of tar balls that continue to be spotted along Grand Isle, Elmer’s Island and Fourchon Beach.
“People are concerned about the chunk of oil that they can’t find counted” in the federal description of how much oil remains in the Gulf of Mexico, Hayward said, and the tar mats explain a small part of the missing oil.
“These tar mats can be three or four or five yards wide and a couple hundred meters long, and they’re discontinuous,” he said. “They’re being found in 2 or 3 feet of water, just below the low-tide line.”
“These are areas where tar balls keep washing ashore,” Hayward said. “The shallow water (where the tar mats are believed to be located) precludes a lot of vessel activity. It’s a very turbulent area.”
WSJ – By BEN CASSELMAN And DANIEL GILBERT
More than two months after the Obama administration lifted its ban on drilling in the deep-water Gulf of Mexico, oil companies are still waiting for approval to drill the first new oil well there. Experts now expect the wait to continue until the second half of 2011, and perhaps into 2012.
The administration says it is simply trying to enforce new safety rules adopted in the wake of the April 20 explosion of the Deepwater Horizon drilling rig, which killed 11 workers and set off the worst offshore oil spill in U.S. history. Environmental groups say the administration is right to take its time because the Gulf disaster exposed the risks of offshore drilling.
But the delay is hurting big oil companies such as Chevron Corp. and Royal Dutch Shell PLC, which have billions of dollars in investments tied up in Gulf projects that are on hold and are paying hundreds of thousands of dollars a day for rigs that aren’t allowed to drill. Smaller operators such as ATP Oil & Gas Corp., which have less flexibility to focus on projects in other regions, have been even harder hit.
The impact of the delays goes beyond the oil industry. The Gulf coast economy has been hit hard by the slowdown in drilling activity, especially because the oil spill also hurt the region’s fishing and tourism industries. The Obama administration in September estimated that 8,000 to 12,000 workers could lose their jobs temporarily as a result of the moratorium; some independent estimates have been much higher.
The slowdown also has long-term implications for U.S. oil production. The Energy Information Administration, the research arm of the Department of Energy, last month predicted that domestic offshore oil production will fall 13% this year from 2010 due to the moratorium and the slow return to drilling; a year ago, the agency predicted offshore production would rise 6% in 2011. The difference: a loss of about 220,000 barrels of oil a day…
Among the new rules: Companies must hire outside engineers to certify key well-safety equipment and subject the gear to more rigorous tests. They require more worker training, more documentation and detailed plans of how they would respond to a worst-case well blowout.
Environmentalists say the Deepwater Horizon disaster proved reviews needed to be more thorough. “The process can work efficiently. Maybe not as quickly as it did before, but that’s understandable,” said Elgie Holstein, a staff expert at the Environmental Defense Fund.
But with no deep-water permits yet issued and companies still struggling to comply with new, tougher safety rules, experts say it could be 2012 before drilling approaches pre-disaster levels. Even when it does, projects that were once approved in weeks will likely take months to get past increased regulatory scrutiny…
Smaller oil companies, however, are less able to wait out the slowdown. ATP Oil & Gas, one of the smallest deep-water operators in the Gulf, has seen its share price fall 27% since the Deepwater Horizon exploded, a sign investors are concerned about lost revenue from its delayed wells. ATP’s chairman, Paul Bulmahn, has said the company is now looking for projects in other countries. In a letter to President Barack Obama last month, Mr. Bulmahn pleaded for a drilling permit…
“But, who cares, it’s done, end of story, [we] will probably be fine and we’ll get a good cement job.”
The Macondo Well and the Blowout
The Root Causes: Failures in Industry and Government
Overarching Management Failures by Industry
Whatever irreducible uncertainty may persist regarding the precise contribution to the blowout of each of several potentially immediate causes, no such uncertainty exists about the blowout’s root causes. The blowout was not the product of a series of aberrational decisions made by rogue industry or government officials that could not have been anticipated or expected to occur again.
Rather, the root causes are systemic and, absent significant reform in both industry practices and government policies, might well recur. The missteps were rooted in systemic failures by industry management (extending beyond BP to contractors that serve many in the industry), and also by failures of government to provide effective regulatory oversight of offshore drilling.
The most significant failure at Macondo—and the clear root cause of the blowout—was a failure of industry management. Most, if not all, of the failures at Macondo can be traced back to underlying failures of management and communication.
Better management of decisionmaking processes within BP and other companies, better communication within and between BP and its contractors, and effective training of key engineering and rig personnel would have prevented the Macondo incident. BP and other operators must have effective systems in place for integrating the various corporate cultures, internal procedures, and decisionmaking protocols of the many different contractors involved in drilling a deepwater well.
BP’s management process did not adequately identify or address risks created by late changes to well design and procedures. BP did not have adequate controls in place to ensure that key decisions in the months leading up to the blowout were safe or sound from an engineering perspective.
While initial well design decisions undergo a serious peerreview process155 and changes to well design are subsequently subject to a management of change (MOC) process,156 changes to drilling procedures in the weeks and days before implementation are typically not subject to any such peer-review or MOC process. At Macondo, such decisions appear to have been made by the BP Macondo team in ad hoc fashion without any formal risk analysis or internal expert review. This appears to have been a key causal factor of the blowout.
A few obvious examples, such as the last-minute confusion regarding whether to run six or 21 centralizers, have already been highlighted. Another clear example is provided by the temporary abandonment procedure used at Macondo. As discussed earlier, that procedure changed dramatically and repeatedly during the week leading up to the blowout.
As of April 12, the plan was to set the cement plug in seawater less than 1,000 feet below the mud line after setting the lockdown sleeve. Two days later, Morel sent an e-mail in which the procedure was to set the cement plug in mud before displacing the riser with seawater. By April 20, the plan had morphed into the one set forth in the “Ops Note”: the crew would remove 3,300 feet of mud from below the mud line and set the cement plug after the riser had been displaced.
There is no readily discernible reason why these temporary abandonment procedures could not have been more thoroughly and rigorously vetted earlier in the design process. It does not appear that the changes to the temporary abandonment procedures went through any sort of formal review at all.
Halliburton and BP’s management processes did not ensure that cement was adequately tested. Halliburton had insufficient controls in place to ensure that laboratory testing was performed in a timely fashion or that test results were vetted rigorously in-house or with the client. In fact, it appears that Halliburton did not even have testing results in its possession showing the Macondo slurry was stable until after the job had been pumped. It is difficult to imagine a clearer failure of management or communication.
The story of the foam stability tests may illuminate management problems within BP as well. By early April, BP team members had recognized the importance of timely cement testing. And by mid-April, BP’s team had identified concerns regarding the timeliness of Halliburton’s testing process.
But despite their recognition that final changes to the cement design (made to accommodate their concerns about lost returns) might increase the risks of foam instability, BP personnel do not appear to have insisted that Halliburton complete its foam stability tests—let alone report the results to BP for review—before ordering primary cementing to begin.
BP, Transocean, and Halliburton failed to communicate adequately. Information appears to have been excessively compartmentalized at Macondo as a result of poor communication. BP did not share important information with its contractors, or sometimes internally even with members of its own team. Contractors did not share important information with BP or each other. As a result, individuals often found themselves making critical decisions without a full appreciation for the context in which they were being made (or even without recognition that the decisions were critical).
For example, many BP and Halliburton employees were aware of the difficulty of the primary cement job. But those issues were for the most part not communicated to the rig crew that conducted the negative-pressure test and monitored the well. It appears that BP did not even communicate many of those issues to its own personnel on the rig—in particular to Bob Kaluza, who was on his first hitch as a Well Site Leader on the Deepwater Horizon.
Similarly, it appears at this time that the BP Well Site Leaders did not consult anyone on shore about the anomalous data observed during the negative-pressure test. Had they done so, the Macondo blowout may not have happened.
Transocean failed to adequately communicate lessons from an earlier near-miss to its crew. Transocean failed to adequately communicate to its crew lessons learned from an eerily similar near-miss on one of its rigs in the North Sea four months prior to the Macondo blowout. On December 23, 2009, gas entered the riser on that rig while the crew was displacing a well with seawater during a completion operation.
As at Macondo, the rig’s crew had already run a negative-pressure test on the lone physical barrier between the pay zone and the rig, and had declared the test a success. The tested barrier nevertheless failed during displacement, resulting in an influx of hydrocarbons. Mud spewed onto the rig floor—but fortunately the crew was able to shut in the well before a blowout occurred. Nearly one metric ton of oil-based mud ended up in the ocean. The incident cost Transocean 11.2 days of additional work and more than 5 million British pounds in expenses.
Transocean subsequently created an internal PowerPoint presentation warning that “[t]ested barriers can fail” and that “risk perception of barrier failure was blinkered by the positive inflow test [negative test].” The presentation noted that “[f]luid displacements for inflow test [negative test] and well clean up operations are not adequately covered in our well control manual or adequately cover displacements in under balanced operations.”
It concluded with a slide titled “Are we ready?” and “WHAT IF?” containing the bullet points: “[h]igh vigilance when reduced to one barrier underbalanced,” “[r]ecognise when going underbalanced—heightened vigilance,” and “[h]ighlight what the kick indicators are when not drilling.”
Transocean eventually sent out an “operations advisory” to some of its fleet (in the North Sea) on April 14, 2010, reiterating many of the lessons learned and warnings from the presentation. It set out “mandatory” actions to take, acknowledging a “Lack of Well Control preparedness during completion phase,” requiring that “[s]tandard well control practices must be maintained through the life span of the well” and stating that “[w]ell programs must specify operations where a single mechanical barrier . . . is in effect and a warning must be included to raise awareness. . . .”
The language in this “advisory” is less pointed and vivid than the language in the earlier PowerPoint. Moreover, according to Transocean, neither the PowerPoint nor this advisory ever made it to the Deepwater Horizon crew.
Transocean has suggested that the North Sea incident and advisory were irrelevant to what happened in the Gulf of Mexico. The December incident in the North Sea occurred during the completion phase and involved failure of a different tested barrier. Those are largely cosmetic differences. The basic facts of both incidents are the same. Had the rig crew been adequately informed of the prior event and trained on its lessons, events at Macondo may have unfolded very differently.
FIGURE 4.10: Examples of Decisions That Increased Risk At Macondo While Potentially Saving Time
Decisionmaking processes at Macondo did not adequately ensure that personnel fully considered the risks created by time- and money-saving decisions. Whether purposeful or not, many of the decisions that BP, Halliburton, and Transocean made that increased the risk of the Macondo blowout clearly saved those companies significant time (and money).
There is nothing inherently wrong with choosing a less-costly or less-time-consuming alternative—as long as it is proven to be equally safe. The problem is that, at least in regard to BP’s Macondo team, there appears to have been no formal system for ensuring that alternative procedures were in fact equally safe.
None of BP’s (or the other companies’) decisions in Figure 4.10 appear to have been subject to a comprehensive and systematic risk-analysis, peer-review, or management of change process. The evidence now available does not show that the BP team members (or other companies’ personnel) responsible for these decisions conducted any sort of formal analysis to assess the relative riskiness of available alternatives.
Corporations understandably encourage cost-saving and efficiency. But given the dangers of deepwater drilling, companies involved must have in place strict policies requiring rigorous analysis and proof that less-costly alternatives are in fact equally safe. If BP had any such policies in place, it does not appear that its Macondo team adhered to them.
Unless companies create and enforce such policies, there is simply too great a risk that financial pressures will systematically bias decisionmaking in favor of time- and costsavings. It is also critical (as described in greater length in Chapter 8 ) that companies implement and maintain a pervasive top-down safety culture (such as the ones described by the ExxonMobil and Shell CEOs at the Commission’s hearing on November 9, 2010) that reward employees and contractors who take action when there is a safety concern even though such action costs the company time and money.
Of course, some decisions will have shorter timelines than others, and a full-blown peerreviewed risk analysis is not always practicable. But even where decisions need to be made in relatively short order, there must be systems in place to ensure that some sort of formal risk analysis takes place when procedures are changed, and that the analysis considers the impact of the decision in the context of all system risks. If it turns out there is insufficient time to perform such an analysis, only proven alternatives should be considered.
Government also failed to provide the oversight necessary to prevent these lapses in judgment and management by private industry. As discussed in Chapter 3, MMS regulations were inadequate to address the risks of deepwater drilling. Many critical aspects of drilling operations were left to industry to decide without agency review.
For instance, there was no requirement, let alone protocol, for a negative-pressure test, the misreading of which was a major contributor to the Macondo blowout. Nor were there detailed requirements related to the testing of the cement essential for well stability.
Responsibilities for these shortfalls are best not assigned to MMS alone. The root cause can be better found by considering how, as described in Chapter 3, efforts to expand regulatory oversight, tighten safety requirements, and provide funding to equip regulators with the resources, personnel, and training needed to be effective were either overtly resisted or not supported by industry, members of Congress, and several administrations. As a result, neither the regulations nor the regulators were asking the tough questions or requiring the demonstration of preparedness that could have avoided the Macondo disaster.
But even if MMS had the resources and political support needed to promulgate the kinds of regulations necessary to reduce risk, it would still have lacked personnel with the kinds of expertise and training needed to enforce those regulations effectively. The significance of inadequate training is underscored by MMS’s approval of BP’s request to set its temporary abandonment plug 3,300 feet below the mud line.
At least in this instance, there was a MMS regulation that potentially applied. MMS regulations state that cement plugs for temporary abandonment should normally be installed “no more than 1,000 feet below the mud line,” but also allow the agency to approve “alternate requirements for subsea wells case-by-case.” Crucially, alternate procedures “must provide a level of safety and environmental protection that equals or surpasses current MMS requirements.”
BP asked for permission to set its unusually deep cement plug in an April 16 permit application to MMS.175 BP stated that it needed to set the plug deep in the well to minimize potential damage to the lockdown sleeve, and said it would increase the length of the cement plug to compensate for the added depth.
An MMS official approved the request in less than 90 minutes.176 The official did so because, after speaking with BP, he was persuaded that 3,000 feet was needed to accommodate setting the lockdown sleeve, which he thought was important to do. It is not clear what, if any, steps the official took to determine whether BP’s proposed procedure would “provide a level of safety . . . that equal[ed] or surpass[ed]” a procedure in which the plug would have been set much higher up in the well.
MMS’s cursory review of the temporary abandonment procedure mirrors BP’s apparent lack of controls governing certain key engineering decisions. Like BP, MMS focused its engineering review on the initial well design, and paid far less attention to key decisions regarding procedures during the drilling of the well. Also like BP, MMS did not assess the full set of risks presented by the temporary abandonment procedure. The limited scope of the regulations is partly to blame. But MMS did not supplement the regulations with the training or the processes that would have provided its permitting official with the guidance and knowledge to make an adequate determination of the procedure’s safety.
Deepwater drilling provides the nation with essential supplies of oil and gas. At the same time, it is an inherently risky business given the enormous pressures and geologic uncertainties present in the formations where oil and gas are found—thousands of feet below the ocean floor. Notwithstanding those inherent risks, the accident of April 20 was avoidable.
It resulted from clear mistakes made in the first instance by BP, Halliburton, and Transocean, and by government officials who, relying too much on industry’s assertions of the safety of their operations, failed to create and apply a program of regulatory oversight that would have properly minimized the risks of deepwater drilling. It is now clear that both industry and government need to reassess and change business practices to minimize the risks of such drilling.
The tragic results of that accident included the immediate deaths of 11 men who worked on the rig, and serious injury to many others on the rig at the time of the explosion. During the next few hours, days, weeks, and ultimately months, BP and the federal government struggled with their next great challenge: containing the spill and coordinating a massive response effort to mitigate the threatened harm to the Gulf of Mexico and to the Gulf coast. They faced the largest offshore oil spill in the nation’s history—and the first from a subsea well located a mile beneath the ocean’s surface.
Download Chapter 4: Advance Chapter on BP Well Blowout Investigation Released
BP Releases Report on Causes of Gulf of Mexico Tragedy
BP has published its internal investigation team’s report into the accident on the Deepwater Horizon rig in the Gulf of Mexico on 20 April 2010.The investigation found that no single factor caused the Macondo well tragedy. Rather, a sequence of failures involving a number of different parties led to the explosion and fire which killed 11 people and caused widespread pollution in the Gulf of Mexico earlier this year.
NRO – By Lou Dolinar
The While House oil-spill commission made it official today: The entire oil industry, not BP, is evil and potentially the source of another Deepwater-sized spill. Thus the entire oil industry, which has already been punished by the administration with its drilling moratorium and slowdown in permitting, should be punished further with massive new regulations and fees.
Those conclusions were virtually predetermined when the administration appointed a panel heavily stacked with academics and environmentalists. And those findings are wrong.
Why? A simple reality check: Other companies drilling in deep water in the Gulf have not had well blow-outs. But in BP’s case, the commission’s own studies show not just one mistake but a series of failed judgment calls by BP officials. Responsibility is specific, not collective. We don’t shut down the airline industry when a plane crashes, and we shouldn’t shut down the oil business.
From the beginning, BP’s peers in the majors — who were not represented in any way on the panel — have contended that BP’s horrendous long-term company safety record makes it an outlier and a rogue, a view echoed by some independent journalists. Highlighting the “rogue” view, just three days ago a leak forced BP, the main stakeholder in Alaska’s Alyeska Pipeline consortium, to shut down the pipeline, which transports 15 percent of American oil production.
Indeed, petroleum experts the administration consulted before it banned drilling in the Gulf actually opposed the move. They said it would not just cost jobs but also punish companies with good safety records. At the time, several Senate Republicans called for hearings into the administration’s distortions, which were so bad that Interior Secretary Salazar was forced to publicly apologize to the scientists and engineers he should have relied on. Those hearings should go forward in the House, and focus in particular on a comparison of BP’s practices with the rest of the industry. They should also focus on the economic impact of further regulation.
Some of the commission’s recommendations — for example, increasing the liability cap for offshore drilling — will require legislation and are likely a dead issue with the shift of power in Congress. While the administration can implement some recommendations by continuing to tie Gulf drilling up in bureaucratic knots, the looming reality of $4-a-gallon gasoline in an election year may outweigh any ideological distaste for Big Oil. With any luck, the commission’s report will disappear with little trace, just like the spill.
Update Final Report (Released 01/11/2011)
Full Final Report (16.76 MB)
Introduction (Front Matter) (1.5 MB)
Part I: The Path to Tragedy (6.85 MB)
Chapter 1 (2.25 MB)
Chapter 2 (4.02 MB)
Chapter 3 (1.05 MB)
Part II: Explosion and Aftermath (15.01 MB)
Chapter 4 (3.22 MB)
The Macondo Well and the Blowout
Chapter 5 (3.77 MB)
Chapter 6 (4.92 MB)
Chapter 7 (3.94 MB)
Recovery and Restoration
Part III: Lessons Learned (6.17 MB)
Chapter 8 (3.49 MB)
Chapter 9 (2.33 MB)
Chapter 10 (1.01 MB)
Back Matter (875.83 KB)
End Notes (335.77 KB)
Appendix A: Commission Members (489 KB)
Appendix B: List of Acronyms (180.47 KB)
Appendix C: Executive Order (221.94 KB)
Appendix D: Commission Staff and Consultants (322.34 KB)
Appendix E: List of Commission Meetings (181.58 KB)
Appendix F: Staff Working Papers (202.02 KB)
Index (538.2 KB)
Recommendations for Decision Makers (7.68 MB)
Download Press Kit (2.38 MB)
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